Comparative study of local infiltration of bupivacaine and parenteral administration of diclofenac sodium for post tonsillectomy pain in adults.


Dr. Nemer Al-Khtoum, MD* department of otolaryngology, royal medical services. Amman - Jordan.


Abstract


Objective: to compare the efficacy of pre-operative local infiltration of local anesthetic (bupivacaine) with the conventional parenteral administration of an NSAID, diclofenac sodium on postoperative pain in adults undergoing tonsillectomy using a standardized anesthetic technique.
Patients and Methods: 120 patients of either sex, age 20 to 40 years posted for tonsillectomy were enrolled and randomly assigned into 2 groups:
Group A: Received diclofenac sodium 1.5 mg/kg intramuscular, 30 min. before surgery (60 patients).
Group B: Received bilateral pre-incisional infiltration of 3 ml of 0.25% bupivacaine in the peritonsillar fossa (60 patients).
Results: Pain intensity after surgery was assessed by asking patients to express there pain on visual analogue scale 0- 100 mm scale ( 0 mm: no pain; 100 mm : maximum imaginable pain) and estimated at 1 hour, 3 hours, 6 hours, 12 hours and 24 hours after surgery.
There was no statistically significant difference between group A and B at all time intervals (p< 0.01).
Conclusion: preincisional infiltration of local anesthetic (bupivacaine) and pre-operative parenteral administration of an NSAID, diclofenac sodium were found to be equally effective methods for treating post tonsillectomy pain.



INTRODUCTION
Tonsillectomy is one of the most frequently performed ambulatory surgical procedures.1The introduction of an electrodissection surgical technique has virtually eliminated immediate postoperative hemorrhage. However, it may cause more pain, discomfort and poor oral intake due to more local inflammation, nerve irritation and laryngeal muscle spasm.2 Pain is still the most significant obstacle to the rehabilitation of a patient following tonsillectomy.
Post tonsillectomy pain has maximum intensity immediately after operation and in the first three post operative days.3 Thus there is a need to achieve adequate pain control, various strategies for the management of post tonsillectomy pain have been proposed like infiltration of local anaesthetic,4,5non-steroidal anti-inflammatory drugs (NSAID)6, narcotics and oral analgesics7. Application of sucralfate as a protective barrier following tonsillectomy has been found to promote healing with significant pain reduction in the post-operative period.8
The aim of this study was to compare the efficacy of pre-operative local infiltration of local anesthetic (bupivacaine) with the conventional parenteral administration of an NSAID, diclofenac sodium on postoperative pain in adults undergoing tonsillectomy using a standardized anesthetic technique.

MATERIALS AND METHODS
This study was conducted in the Department of Otorhinolaryngology, Royal medical services, Jordan, in the period from June 2003 to July 2005.
After an informed written individual consent was taken, 120 patients of either sex, age 20 to 40 years posted for tonsillectomy were enrolled the indication being chronic tonsillitis, recurrent episodes of acute tonsillitis.
Cases of peritonsillitis, peritonsillar abscess, neoplastic lesions, patients with a known allergy to the drugs being used, asthma, kidney, or hepatic dysfunction or hemorrhagic diathesis were excluded.
Patients were randomly assigned to each group using a list of random numbers, and received either of the two treatment modalities.
Group A: Received diclofenac sodium 1.5 mg/kg intramuscular, 30 min. before surgery (60 patients).
Group B: Received bilateral pre-incisional infiltration of 3 ml of 0.25% bupivacaine in the peritonsillar fossa (60 patients).
All the tonsillectomies were performed using a standardized anesthetic technique. By one surgeon employing the blunt dissection technique (Boyle-Davies). The bleeding was controlled by bipolar diathermy or ligation.
Pain was estimated in all patients by an independent observer. Visual analogue score (VAS) was assessed on a 0- 100 mm scale ( 0 mm: no pain; 100 mm : maximum imaginable pain) and estimated at 1 hour, 3 hours, 6 hours, 12 hours and 24 hours after surgery.

RESULTS
There was no significant difference in demographic data between the two groups.
The mean post-operative pain scores for group A at 1 hour, 3 hours, 6 hours, 12 hours and 24 hours after surgery were (26.25±6.66, 32.00±5.47, 30.50±4.84, 14.25±4.37, 9.5±1.53) respectively.
The mean post-operative pain scores for group B at 1 hour, 3 hours, 6 hours, 12 hours and 24 hours after surgery were (28.50±4.89, 32.00±4.47, 30.57±4.84, 17.25±5.97, 8.7±1.37) respectively.
There was no statistically significant difference between group A and B at all time intervals (p< 0.01).


DISCUSSION
The reduction of post-tonsillectomy pain is important not only for the patient comfort, but also because reducing pain improves oral intake, reduces the risk of dehydration, infection and post surgery hemorrhage. 9
Throat pain, referred otalgia and bleeding after tonsillectomy contribute to making recuperation difficult and prolonged. Therefore adequate analgesia is necessary to relieve the agony of pain and reduce incidence of bleeding since increased vascular congestion of the head and neck associated with crying may precipitate bleeding10.The most common method of providing postoperative analgesia is systemic administration of narcotic analgesics though these drugs have their own side effects.
Post tonsillectomy pain is probably the result of muscle spasm caused by inflammation and irritation of the pharyngeal musculature. 8
Bupivacaine is an amide- linked local analgesic. It was synthesized by Ekenstan in 1957 and has been used extensively in obstetric practice to produce epidural analgesia and peripheral nerve blockade in the management of intractable pain. It's high lipid solubility and protein binding results in rapid onset of action and prolonged duration (6-9 hours). The recommended upper limit of safe dosage of bupivacaine is 2mg/kg body weight.11Systemic toxicity produces arrhythmia, drowsiness, convulsions, paraesthesia, disorientation and nystagmus.
Diclofenac sodium 1 mg/kg intramuscular, given after induction of anaesthesia was found to be an effective alternative to opiates in tonsillectomy patients. 7
During surgery, pain impulses entering the central nervous system, create a hyperexcitable state inspite of general anaesthesia. Blockade of these impulses by preoperative analgesic drugs12 or infiltration of local anaesthetic agents has a pre-emptive analgesic effect.4 Therefore we planned to give parenteral diclofenac and local infiltration before the tissue trauma.
Conclusion
Our results showed that Preoperative diclofenac in group A and preincisional infiltration in group B were found to be equally effective methods for treating post tonsillectomy pain.

REFERENCES

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3. Warnock FF, Lander J. Pain progression. Intensity and outcomes following tonsillectomy. Pain 1998; 75: 37-45.
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5. Stuart JC, MacGregor FB, Cairns CS, Chandrachud HR : Peritonsillar infiltration with bupivacaine for paediatric tonsillectomy. Anaes and Intensive care 1994 ; 22 : 679-82.
6. Raj TB, Wickham MH : The effect of benzydamine hydrochloride (difflam) spray on post-tonsillectomy symptoms : A double blind study. The J of Laryngol Otol 1986 ; 100 : 303-6.
7. Watters CH, Patterson CC, Mathews HML, Campbell W : Diclofenac sodium for post-tonsillectomy pain in children. Anaesthesia 1988 ; 43:641-3.
8. Freeman SB and Markwell JK : Sucralfate in alleviating posttonsillectomy pain. Laryngoscope 1992 ; 102 : 1242-6.
9. Husband AD, Davis A. Pain after tonsillectomy. Clin Otolaryngol 1996; 21: 99 101.
10. Hannington — Kiff JG : The need for analgesic cover after ENT surgery — comparison of nefopam and papaveretum. Anaesthesia 1985 ; 40 : 76-8
11. Martindale the Extra Pharmacopoeia. The Pharmaceutical Press, London: 1982, pp. 910-12.
12. Jakobsson J, Rane K, Davidson S : Intramuscular NSAIDS reduce post-operative pain after minor out patient anaesthesia. Eur J Anaesthesiol 1996 ; 13: 67-71.


*Correspondence should be addressed to:
DR. Nemer Al- Khtoum.
Department of ENT. RMS. Jordan Armed Forces.
Amman- Jordan
PO Box – Sweileh 1834
Email;nemer72@gmail.com

 

 

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First Published 23-Sep-2005 3:21 PM